Hey loves!  Today was just another day in pediatric otolaryngology (ENT (Ear, Nose and Throat)).  But we had two pretty crazy cases and an interesting consult.

1) Consults first: another fishbone stuck in the base of a tongue.  This unfortunate patient was eating bluegill and got a bone stuck that wouldn’t dislodge despite eating large chunks of bread and other food.  We saw the bone on direct laryngoscopy with a flexible scope inserted through one of the nasal passages.  The ER docs provided conscious sedation and we used a rigid laryngoscope to look down her throat, isolate the bone and pick it out with super long skinny forceps like those used in laparascopic surgery.  The bone was maybe a centimeter long and maybe a millimeter thick.  It was pretty hard to see unless against a dark background.  Crazy that something so little could cause so much irritation…

2) A toddler had an ossifying fibroma, which is a benign tumor where bone and bone marrow overgrow, usually in the face or jaw.  This poor kid has it in his posterior orbits (eye sockets) and has already lost vision in one eye despite previous surgeries.  So we decompressed his other optic nerve (vision nerve) by going through the nose, through the maxillary sinus, crushed the ethmoid air cells, through the sphenoid sinus and next to the orbit.  The optic nerve was completely exposed in that area so that it was no longer compressed by irregularly growing bone.  CRAZY COOL.

3) And the third crazy thing.  Yesterday we did a brief surgery on a kid with a nasal dermoid, another benign growth, just between his eyebrows.  It was quick because it was all extracranial (outside the calvaria which houses your brain).  Today a kid had the same thing, but was much less fortunate.  It had eroded through the bone and was growing on top of his brain.  Neurosurgery did most of the case, and made a large sinusoidal-like incision on top of his head.  His skin and periostium was pulled down over his face and a large chunk of bone cut out.  The bony plate was housed somewhere safe for a few hours while the surgeons cleaned up the brain.  I couldn’t believe the brain was just sitting there right in front of me, completely exposed.  Another chunk of bone was taken out of the top of the head and stitched into the hole made by the tumor, the large bony plate was attached with metal clips and the skin sewed back up.  SUPER CRAZY.

• Cool thing I learned today: The Finger test is a test used to diagnose necrotizing fasciitis (which unfortunately one of my roomies’ patients may have….)  Local anesthetic is injected into the an affected area and a 2cm incision is made along the lesion.  If it doesn’t bleed, it’s likely necrotizing fasciitis.  A gloved index finger is then placed inside the cut.  If the tissue is dissected easily and falls apart with gentle pressure, it is even more likely it is necrotizing fasciitis.
• Spanish word of the day: sueño = sleep.  “Tango sueño” = I’m sleepy (I have sleepiness)
• Tip for med school success: Have I mentioned sleep before?? Oh yeah, I have.  Mostly because it’s the most important thing to do for learning success.  Last month I was getting 7-8hrs per night and feeling great.  My mood and attention span were awesome.  This week I’ve only gotten ~6hrs per night and can’t concentrate on anything for very long….it’s frustrating when studying for a surgery shelf.  So don’t be like me! Get your rest!

In about 3 weeks I will be a fourth year medical student. THAT BLOWS MY MIND.  I’m on anesthesia this week and loving life!  Anesthesia is a crazy mix of pharmacology and physiology with a bunch of procedures mixed in.  It’s like critical care in surgery.  At the beginning and end of cases and when things go less than perfectly, it’s crazy and adrenaline rush-inducing and then in the middle it’s pretty low key.  I personally like it a whole lot better than surgery.  But for subspecialty I am on ENT (ear, nose and throat), which is actually pretty cool.  One day in clinic we removed a fish bone from someone’s throat and had a patient that would sneeze snot out of a tooth socket.  I’ve been in on surgeries to dissect neck lymph nodes for cancer staging, create a new tongue from a breast flap and fix multiple jaws from bar fights and car accidents.   The attendings and residents are all very nice and helpful and they let me do a lot.  It’s a good mix of surgery and clinic time (still full of procedures) and it is a much more inviting and nurturing environment than general surgery seemed to be.  If I liked surgery in any way at all I would consider doing ENT.

That brings me to my next big news: I’m pretty sure that I’ve maybe officially decided to go into Family Medicine.  I want to have an emphasis on Functional Medicine and OB.  What is functional medicine you say?  It’s a mix between conventional and integrative medicine, which combines multiple modalities to treat both acute and chronic problems, but often focuses on chronic disease states that no one else wants to touch, such as chronic fatigue syndrome and fibromyalgia.  It is all about getting the body into a healthful state so that it can heal itself and respond appropriately to stimuli and not overrespond to normal things like minor pain.  It includes things like fixing mitochondrial imbalance using L-carnitine and D-ribose, things that go into the Krebs’ cycle and make total sense biochemically and physiologically, but aren’t studied as much in literature because these supplements are less accepted as actual treatments and less likely to make money because of patents like normal new drugs.  Functional medicine is about treating acutely with conventional medicine while ultimately striving to cure the hypertension, chronic pain, insomnia, depression, etc. instead of just covering it up.  I think it fits quite well into the family practice I dream of having one day. Click here for info on Functional Medicine!

Third year has been incredible. It’s hard to imagine being ready to be an intern one year from now, but then again I didn’t think I would know near as much as I do now at the end of this year.  The first day of third year seemed so daunting, and now everyday is just an exciting day of what trouble can I get myself into and learning from it by having the residents and faculty teach me as I am failing miserably.  Example: I keep forgetting to take the tourniquet off when placing an IV and having been getting bloody shoes all week.  Example 2: My intubation technique is slowly improving but I’m realizing how weak my little biceps truly are.  Note to everyone entering third year: do more pushups and military presses.

• Cool thing  I learned today: One of our patients was having a parathyroidectomy, and the surgeons wanted to be able to test his recurrent laryngeal nerve function at the end of the case.  This meant that we couldn’t paralyze the patient throughout the case because then it would have been impossible to see the muscle twitches evoked with a nerve stimulator (normally patients are paralyzed during surgery so that we can successfully keep them intubated and they won’t move on the table and important structures won’t get accidentally cut or burnt).  So we had to put the patient into a deeper anesthetic state so that he would not move or try to breath on his own.  Pretty cool stuff.
• Spanish word of the day: Cuidate = take care.  Good end of a conversation =)
• How to survive third year: If you haven’t already done those pushups, GET ON IT!  Also, buy a pair of Danskos.  Sure they may be ugly and slightly expensive (~$110 if you go to Goodman shoes and take your med student ID with you), but your feet won’t hurt at the end of the day and you won’t care that you got blood and fluids all over them, they were already ugly!  Seriously, start doing some Taibo.  You will enjoy the extra strength.

Here’s an amazing pic of Juan and Sister Jack (my fiance and cat in case you’ve been living under a rock and haven’t been reading my blog!!) =)  Yes, she is inside his jacket looking like a dude with her long mustache whiskers!

I started OBGYN last week at Wishard hospital.  Each day rotates between clinic, surgery and labor & delivery.  In clinic we do OB visits, annual exams with Pap smears and things like LEEP procedures (look it up but be prepared, your cervix will hurt just thinking about it…).  OR days include hysterectomies, ovarian cyst removals, endometrial tissue biopsies and a lot more.  L&D is well, the BEST THING EVER.  Babies everywhere.  And every kind of bodily fluid imagineable everywhere.  I’ve been amazed at the positive attitudes and commitment to teaching shown by the residents.  They make time to allow us, as students, to practice procedures or help with suturing, even in times of high stress, which leads me to the “reality” of OBGYN when things are good, they are great.  And when they are bad, they are unthinkable.

Each of us students get to spend one week on nights helping with deliveries and triaging patients with bleeding during pregnancy, preterm contractions, etc.  A few days ago I was on nights and we were busy triaging patients to see which should be admitted for delivery and which could go home until their true labor started.  We were called urgently into one of the rooms for a patient who had developed copious vaginal bleeding a few hours before.  It’s not uncommon to have spotting during pregnancy for a number of reasons, and some women experience bleeding when their “water breaks” during labor.  This was different.  She was brought up to our floor with fetal heart rate in the 60s (normal is 110-160 for a neonate).  She was between 32 and 34 weeks (term is 39 weeks) and had had no prenatal care.  While the residents were frantically searching for a heartbeat with ultrasound, I happened to glance at the urine sample she had just given.  This wasn’t the expected “tea-colored” urine common with vaginal bleeding.  There was no urine in the cup.  It was straight-up blood.  When the fetal heart tones couldn’t be located we ran to the OR.  While on the way to the OR she admitted to cocaine use the night before.

Since starting surgery block I’ve learned that there is a TON of tedious but important prep that happens in the OR before each surgery, consisting of cleaning the room, setting up all the possible equipment sterily, cleaning the patient, putting them to sleep, scrubbing in, prepping the sterile field around the patient and taking multiple time outs to ensure proper patient and proper procedure.  This all usually takes 20-30 mins.

This OR visit was complete chaos.  Anesthesiologists, OBGYNs, NICU docs and nurses for all of them were scrambling at once for supplies and gowns.  I grabbed my mask and hair cap and tried to stand out of the way which was proving to be fruitless.  I was quickly called over by an anesthesiologist attending to hold the oxygen mask while they put in IVs and got drugs ready.  I also held pressure on the esophagus while they intubated to ensure proper placement in the trachea and prevent reflux and aspiration of stomach contents since our patient hadn’t had the normal eight hours of fasting before surgery.  I tried to stand in as  little space as possible while residents passed tubing, clips and EKG leads around me.

Once our patient was prepped the OB residents started cutting.  I watched them cut the skin, muscles, fascia and finally the uterus, pulling out a pale but large enough baby girl.  What felt like 10 mins as I held my breath actually took only a few seconds.  The residents tried to stop the bleeding as they examined the uterus that had just held an abrupted placenta.  While they threw bloody rags and placenta pieces around me the chief resident took time to tell me to scrub in.  I rushed to get cleaned and gowned and the attending and residents showed me the 75% abruption.  The uterus was gray and bruised, quite a stark contrast from the normally red and glistening gravid uterus.  There was a fibroid and also old scarring, suggesting past pelvic inflammatory disease.  They had me retract the skin while they sewed the uterus and fascia back together while the NICU staff ran to get blood and frantically tried to resuscitate the baby who initially had a heart rate in the 20s but wasn’t breathing.

The chief resident took time to help me sew up the skin, even though I’m painfully slow, so much so that the muscle relaxants were wearing off and abdominal wall was moving with each of her breaths as I tried to finish sewing.  As we finished cleaning her up, the NICU staff pronounced the time of death for the baby.  They wrapped her up in a blanket and hat just like all the newborns as we took her mom to the PACU.  The amazing nurses took the prettiest baby I have ever seen, dressed her in a white dress and bonnet and took pictures to make a little album for her family of pics of her little hands and feet and angelic face.  The mother got to hold her to say goodbye and they kept her safe until the father of the baby was able to come to the hospital as well.

The mood was somber for the rest of the night.  The residents made sure I was ok and answered all my questions as they replayed the events outloud, trying to find where they might have messed up by delaying the diagnosis or the decision to go to surgery or the delivery, knowing they full well did exactly as they should have.  They explained to me that lots of patients use cocaine and various other drugs during pregnancy that only rarely have devastating outcomes.  But this patient just happened to have a perfect storm of past medical history that predisposed her to disaster if any other insults were added.  Abruption is a gravely feared event with a 35% fetal mortality.

But we went on our way appropriately tending to other patients.  Later that night I helped with my first vaginal delivery.  It was incredible.  The baby quickly adjusted to life on land, even smiling and looking around with huge, beautiful, brown eyes.  I could have cried, both from happiness and also from cringing at the second degree laceration the mom incurred as she ripped through her vagina and perineal body.  If the anticipated pain of labor hadn’t convinced me to want an epidural if I should be so lucky to have a kid someday, watching the laceration did.  I can’t imagine being able to feel a baby’s noggin rip a giant hole down there.  But regardless, it was a much-needed moment of sheer joy at this young family’s firstborn’s birth day.

I’ve watched patients die before, from coding due to multiple comorbidities combined with age, from trauma and even from brainstem herniation.  All of these events sucked.  A lot.  But nothing gave me seemingly never-ending chills like watching a perfectly viable pregnancy end in unnecessary death.  Med school life lesson #561: learn to accept death of all kinds while still striving to prevent it and prolong meaningful life.  Do all this all the while stop yourself from being judgmental and angry at the people who may be responsible.  Part of me was fraught with rage at the mother but for some reason my chills kept me cooled down.  My chief resident was able to explain what I and they were feeling but that I couldn’t describe. 1) There are so many people who would give everything to take care of a perfect baby, including this little girl.  2) It’s absolutely unimaginable to lose a child.  Period.  And living with that for the rest of your life? Unthinkable.

And so in the end we rightfully sympathize with mother, not even remotely condoning or excusing her actions but rather ignoring that fact and validating her pain at the death of part of her.

Just when you think med school is getting easier, it doesn’t.

My last few days of vacation are coming to an end….although I love third year and am excited to go back, it’s only half-heartedly that I trade the bliss of sleeping until 11:00, eating whenever I choose, planning a wedding and going to yoga class in the middle of the day and lazing about for hours with Sister Jack for sleeping until 4:00am, eating whenever time allows, planning a study schedule and going to the operating room in the middle of the day.  Surgery seems daunting to me and I have no idea what to expect.  I’ll keep you updated on the craziness, don’t you worry.

• Cool thing I learned while on vacation: Meditation and relaxation are something most Americans don’t think about on a daily basis, me included.  But using a Groupon for 10 yoga classes this month has really opened my eyes to its importance.  I’ve done yoga in the past and listened to relaxation videos when having trouble sleeping, but I never experienced the full benefits.  Deep breathing is so good for body and mind, “in the moment” relaxation is incredibly good for mind and spiritual awareness and stretching and lengthening through yoga postures is so amazing to reverse all the bad posture we have while sitting or standing for hours on end.  I used to HATE yoga because I’m not flexible, but going to a class and getting stronger and learning to breathe correctly has been wonderful and I recommend to everyone, ESPECIALLY guys, who seem to think that yoga is a “girl” activity.  I assure you it can be incredibly challenging, require a lot of strength and is amazingly soothing and brings awareness to the whole body.  Done with soapbox about yoga.
• Medical Spanish: I’ve worked a bit on my Spanish over break, and now I can say, “Mi gata bebe su leche” = my cat drinks her milk
• Tip for success in medical school: Don’t freak out when you get a clerkship assignment.  I’m terrified of mine, but it could be a wonderful experience and it’s really dependent on you.  My challenge will be to make it good by removing my negative preconceptions.

Well, I’ve been on vacation the past few months. Third and fourth years are AWESOME not only because you are in the hospitals and offices but because you get vacation too! I’ve been using my time off to rest, get back to exercising, trying a few new recipes and planning a wedding! I am very happy to announce I am getting married about a year from now, January 11th, 2014!! Planning a wedding is sometimes more stressful than even med school….but I feel very blessed to find someone who can put up with my crazy schedule and ambitious goals.  Aside from that, I’ve been babysitting my lovely niece for the past week.  I had lots of plans of fun things to do with her, but then I learned an important lesson….you can’t count on doing anything with a two year old…and my medicine/nurturing skills got put to the test.  She came to Indiana with a bad case of gastroenteritis….and today she is finally feeling better, but of course it’s her last day here.

In other news I’ve been considering what I want to do as a doctor and I’ve narrowed it down to a few things.  After completing medicine, pediatrics and now family medicine clerkships I know that I want to work with both kids and adults, which leaves me with family medicine or med/peds.  I’m still quite interested in rheumatology and I haven’t even started surgery block yet, so I still have lots of time to decide.

I started to read the book, “How Doctors Think,” which I got for Christmas.  So far it’s very interesting and discusses how some doctors today get caught up in having to see so many patients every day and go through simple algorithms quickly in their minds while trying to diagnose a patient’s problem and how we need to go back to thinking about the person as a whole.  I’ll keep you updated as I read on.

• Key to success in medical school: Always keep an open mind!  As I think I’m getting better at seeing patients and deciphering everything that’s going on, I do get caught up in simple algorithms sometimes and forget to see the whole patient.  My preceptor last month could decipher when a complaint was one of the subtle signs of depression and not just a transient complaint.  I want to be like that, figuring out how a patient’s physical, emotional and social lives all affect their health.

So family medicine. I had a few preconceived notions about what it would be like, lots of diabetes, hypertension, heart failure and upper respiratory tract infections. So much fun. Not. And I thought I knew what living in a small town would be like. BORRRRIINNNGGGG. Well, part of this was right, there is a lot of hypertension and URI’s and sometimes the small town can be boring, but I am pleasantly surprised to tell you that I am LOVING IT. Another cool thing about IU, you feel like there are a ton of med students and how can they attend to each one of us? Well for family med they do try to give us unique experiences that we probably would not get elsewhere by sending most of us out of Indy and out into communities throughout the state. I got put in North Judson. “Where the **** is North Judson?!” I initially asked. Well it’s in the middle of nowhere by Plymouth. Where’s that? Somewhere by LaPorte and Valpo. Well that didn’t really help me, but here I am in the country and it is wonderful. Everyone knows everyone, everyone takes care of everyone and people are generally nice to each other. There are the common small town problems of people sometimes knowing too much of everyone’s business and Lord help me if I get stranded at 11pm because the gas station will NOT be open, but so far things have been very good.

Everyone loves my preceptor and he is absolutely wonderful. I get to see patients before the doctor, make suggestions, ask questions and help with procedures. I am learning a ton about treating, diagnosing and managing all kinds of conditions, but I am learning a lot of the intangibles as well. Out in the country family med seems more like it used to be, docs take care of almost everything, they sterilize and reuse things instead of throwing everything away, they play the game of finding the cheapest alternatives like they do in the city, but they seem to be better at it. Other family docs that I’ve shadowed were generally very nice and seemed capable, but seemed to feel under a lot of pressure to refer to other doctors. I would get so frustrated that every muscle ache was sent to ortho and every stomach problem was sent to GI. It seemed so wasteful, time-consuming and not very much fun. Here specialists are still consulted when necessary, but usually the doc will try to figure out if it’s something he can treat before sending someone 40 miles away. I really like that. It makes me feel like an all-around doctor, being able to diagnose and treat every body system.

Which brings me to a conundrum. When I first wanted to be a doctor I imagined myself as a family doc, being able to diagnose everything and create relationships with people. But growing up I never had a family doctor that seemed very interested in that or seemed to have enough time to even say hello before rushing into the exam. Maybe it’s a city thing. Maybe it’s an administration thing. Maybe it’s a shortage thing. I’m not sure, but what I do know is that there is a huge and growing shortage of family docs and to be frank, very few of my colleagues are even considering family med because of the stigma that it is a lower profession than other specialties. And it is a concern and deterrent for me that female physicians who go into family medicine have a harder time paying off their school loans and through their lifetimes make less money than female physician assistants or nurse practioners that work in family medicine, although they have more training and more autonomy. I think PAs and NPs are great and can work well in family medicine, but I’m not sure how to convince myself or any of my colleagues to go into it if we can’t make enough to live after paying our loan bills each month. And this will inevitably facilitate a larger shortage, higher patient load for existing family docs, less time with each patient and even less comprehensive, attentive and preventative care for patients. This downward spiral seems like an impending disaster to me.

I certainly don’t know the answers to any of these questions but I hope that they get answered sooner than later.
But on the bright side I am having a wonderful month here in North Judson and I recommend the experience here to anyone! =)

• Cool thing I just learned: Married men live a lot longer than single men.  And it’s amazing how many men don’t know what medicines they are on because their wives set up their meds for them every day.  Crazy, but adorable.
• Tip for surviving med school: No matter how much you think you need to study, always make time for family, especially over the holiday season.  I was planning on staying here this weekend to catch up on studying but made a last minute decision to visit my parents and Sister Jack in Fort Wayne.  Didn’t get much studying done, but it was a fantastic decision!  Now I’m refreshed and ready to study, not dreading it like I was.

If any of you lovely people have a question or a topic you would like to hear about please let me know!

The last few weeks I’ve been on the inpatient pediatric hematology/oncology service at Riley.  It has been an enlightening and heart-wrenching experience.  I was hoping to find uplifting stories of kids going through horrible chemo and coming out normal kids on the other end.  I did find these stories, but more often than not I found incredibly sick kids who have raging infections from the chemo-induced immune system suppression and kids with sickle cell disease going through a vaso-occlusive pain crisis with buttons connected to IVs of morphine.  I have been inspired by these kids’ resiliency but also saddened by these terrible diseases.  Going through chemo itself is a carcinogenic, side effect-laden event filled with scheduled doses of anti-emetics, high-dose narcotics and big-gun antibiotics for any little fever.  Kids getting stem-cell transplants for various leukemias or immune deficiencies are confined to their rooms for days.  GI tracts are torn apart and patients get horrible mouth sores and peri-anal sores making it a horrific process to try to eat or defecate, two very normal everyday processes that I guess I was taking for granted…

All in all, cancer is a horrible, horrible disease and after being confronted with it head-on, I’m not sure how aggressively I would choose to treat it if heaven-forbid my body turns against me and I get it.  The doctors, nurses, residents, interns and other staff are simply amazing and eager to help and teach, which makes working on the hem/onc ward bearable.  And helping the kids decorate their rooms or celebrate a birthday or talk about the latest movies made me feel useful, human and more like myself, but knowing the fact that these kids decorate their rooms because they are here for months on end just seems so unfair.  Some patients take off an entire year of school.  Obviously that puts them behind in their learning, but the social impact is far greater.  Can you imagine going back to your school when everyone knows you had an incredibly serious illness, but they probably don’t understand all of it and facing the eyes and ears of everyone?  Strong personalities would do great with the attention and be able to make good come out of the experience.  But seeing all your old friends in a grade above you, not in your classes, not in your events has to be incredibly tough.  In college or post-undergrad schooling it would be no big deal, but in grade school or high school that has to be an incredibly difficult task to accept coming back to an incredibly different world a year later.

I for some reason (probably because I kept forgetting at the beginning of the month) haven’t been doing the facebook post-something-every-day-in-november-about-what-you-are-thankful-for, but if I did today would say, “Here’s to the hem/onc kids!  They are much braver and stronger than I, and their hopeful and energizing attitudes keep me searching for answers and solutions to all of their medical and non-medical problems and difficulties, big and small.  I am so thankful for the wonderful kids I met and the strong and loyal parents and caregivers that put the rest of their lives on hold to be there for them.  I hope that I am learning to be that courageous and giving in even a fractional amount of what they are.  God bless them all!”  And I would mean every word.

This rotation was the first that I cried when I got home and the first where I felt utterly and completely exacerbated some days.  I came close on other rotations, but with adults that have dug themselves an early grave it is much more difficult to be completely open and empathetic.  Although I feel for them and would do everything I could to help them medically and socially, seeing a kid who has done nothing but go to school every day, play outside, play video games, smile, giggle, imagine and love those around them unconditionally suffer through a body-eating disease is somewhat inconceivable.  Sometimes I would find myself drifting away during rounds, almost feeling like some of the daily reports weren’t real, they couldn’t be.  In my mind, “this patient was fine last week, just here for routine chemo.  Now they are going into a steady decline and have metastases all over their body?  That can’t be.  I must be imagining it.  Plan? Check.  Orders? Check.  Ok, moving on…” and just go through the rest of rounds sheltering myself by remaining on a cloud far away from reality.  Not a great mindset for learning, innovating or being realistic, and by the very end I was able to keep myself focused and in the moment, but sometimes I wished I hadn’t.

Although hem/onc is clearly not for me, I have an incredible respect for everyone who works on that floor and every patient and family on that floor.  So here’s to everyone I met on hem/onc.  Thanks for teaching me invaluable lessons in medicine and in life.

The other day I got to spend the afternoon with Child Life, the super cool program at Riley that incorporates play, art therapy, music therapy, medical procedure teaching/de-frightening, school help and lots of other stuff to help patients have a better stay. Here’s an excerpt from my debriefing paragraph:

I was excited to spend the afternoon with Child Life after hearing all the things that they provide, but I had no idea what to expect.  I happened to be assigned to the pulmonary floor for play time.  Upon hearing this I expected to spend time playing with the kids in the playroom on that floor, but kids on the pulmonary floor typically have to be in isolation.  So definitely no playroom.  We went to the first child’s room to make a working clock out of paper mache, cardboard and stickers.  I was going to go around with the Child Life leader to the other kids’ rooms but she asked me to stay with that girl because her family was never able to see her during the day.  She has CF, so every time she’s admitted it’s a 14 day course of antibiotics.  That’s 14 days of sitting in one room by yourself.  But the Child Life crew had helped her set up her room like a home.  Her bed was the bedroom, couch and chair was the living room and a small area with mats by her bed was the play room where she kept all her toys and art projects she had worked on while in the hospital.  After making the clock we played some games and then played school.  She was the teacher and I was the student.  It was just like how I had played with my sister growing up.  The only difference was that I was now wearing gloves and an isolation gown.  If I hadn’t known she had CF I would have assumed she was a healthy otherwise normal girl.  She had the same imagination, the same desire for social interaction, the same love of breadsticks and milkshakes that any other kid would have.  Her room, just like all the rooms, had a huge tv in it.  But she never once mentioned it and it wasn’t turned on.  And no matter how fancy or how modern her room was, all she wanted was to pretend and play and have friends just like everyone else.  It was a wonderful experience getting to play with her and realize all the factors that go into a long hospital stay that I would never think of otherwise.  I’ve seen so many bored and lonely adults at other hospitals and I wish there were programs like Child Life everywhere.  I think they would make hospital stays shorter and interventions more successful.

It was a great experience to get out of my white coat, take off my stethoscope and not care about what antibiotic she was getting in her IV.  Kids are awesome.  They always surprise you. =)

• Cool thing I learned today: You can get Giardia infection from drinking well water.  Copious watery/mucousy diarrhea for weeks from well water??  Yeah….I’m gonna skip on the sulfur water from now on, thanks.

Guys, this week is amazing. I started my Pediatrics rotation with a month of outpatient/low intensity inpatient. This week I am at the newborn nursery in Wishard. OH. MY. GOODNESS. I have never actually seen a baby that was less than a few weeks old before and they are UNBELIEVABLY adorable.  I’ve learned how to do a head to toe newborn exam and a lot of what to expect with the first few weeks of life.  Did you know that newborns have stomachs the size of a ping pong ball?? And that 5-10mL is a normal feeding? That’s milliliters, people.  That’s crazy!  I usually don’t get this excited about learning new things, but wow. They are amazing.  They cry and it’s adorable because it’s not very loud yet and feeding them makes them stop immediately.  They can’t do much except lay there and be cute so there’s no trouble to be had!

I’ve learned a lot about neonatal skin lesions and that most of them are benign.  There are tons of rash-like things and dry skin and spots and nevi (moles) and they are almost all benign.  But if there are lumps and bumps and redness on the palms and soles, it is syphilis until proven otherwise.  The interesting but hard to remember and super sad thing about newborn babies is that if they are infected with a TORCHES infection in utero they present often completely differently than their mother or any adult would.  TORCHES is just an acronym for some of the infections that cause problems in fetuses, like toxoplasmosis, rubella, CMV (usually only presents as one type of mononucleosis), herpes, syphilis and several others.  In newborns with syphilis they have a rash, adults don’t get a rash until months or years after they are infected.  If the mom gets rubella, they have German measles for a few days and usually no big deal.  But if they get it during the first trimester of pregnancy, the baby can have all kinds of malformations, hearing problems, cataracts, mental retardation, bone marrow, spleen and liver changes and a whole list of other things.

I’ve also learned about breastfeeding.  The US has a terrible level of breastfeeding moms for various reasons, but it is a big problem.  There are so many benefits to breastfeeding and it’s a shame that more mothers don’t.  Current recommendations suggest exclusively breast feeding for six months and continuing with food supplementation for at least up to one year of age.

Some of the benefits of any/exclusive breast-feeding include:

• 72% decrease in hospitalizations for lower respiratory tract infections
• 64% decrease in GI infections
• 58% decrease in necrotizing enterocolitis
• 36% reduction in risk of SIDS
• decrease in allergies and eczema
• 31% reduction in risk of childhood inflammatory bowel disease (ulcerative colitis and Crohn’s)
• 52% reduction in risk of celiac disease
• 15-30% reduction in adolescent and adult obesity
• 30% reduction in type 1 diabetes
• decrease in childhood leukemia
• higher intelligence scores and teacher ratings
• decreased maternal postpartum bleeding
• faster maternal uterus involution
• decrease in maternal post-partum depression
• decrease in rate of child abuse/neglect
• decrease in maternal breast and ovarian cancer
• and if 90% of US mothers stuck to guidelines, there would be a savings of $13 BILLION per year

Obviously, there are some contraindications or problems with breast feeding, like childhood galactosemia, PKU, maternal HTLV/TB/active herpes and HIV in industrialized countries.   It can also be an inconvenience if a new mom needs to go back to work and cannot stop every few hours to pump milk/breast feed.  BUT if the problem is maternally physiologic, there are breastmilk banks with pasteurized milk from donors that can be utilized for babies.  I had no idea this was a big deal.

Also last week we had ACLS training.  I can now run a code.  So if someone goes into cardiac or respiratory arrest I know what to do and technically know how to be in charge….that’s crazy.

•  Cool thing I learned today: Newborns typically lose about 10% of their weight in the first few weeks of life.
• Medical Spanish: Still on hiatus…I apologize…
• Tip for med school: Come to school every day eager to learn something.  Even if you feel awful strive to learn at least a few things or improve on one skill.  You can always look at your notes later or ask questions later, but if you can gain something out of each day, then the $330 you paid for that day is worth it and more importantly your time and energy was worth it and you will be a better doctor because of it.  It’s hard to see the light when people ask you how much longer you have and you spout off multiple years…but every day is a gift and every day is important. =)  Cheers!

Hey loves! Hope your October is cheery and bright so far! I have a less cheery (maybe?) subject to discuss today that really impacted me last month on inpatient internal medicine, end of life (EOL).  Working in a hospital you are a part of many types of EOL discussions from those facing their own mortality, families facing a loved one’s mortality, fear of the unknown, patients who are obtunded and don’t know that EOL is near, etc.  I sat in on several code status conversations, one of which was very emotional and trying.  A daughter, the primary caregiver of a patient at their own EOL, faced the tough choice of putting her parent as a DNR, knowing that her condition was deteriorating.  The daughter had actually successfully resuscitated her parent before hospital admission and the parent was almost completely back to baseline.  But knowing that a second cardiac arrest would be almost certainly less successful made it difficult to justify a second attempt should it happen again.  The situation definitely made me think about what I would feel if it was my own family member and how heartbreaking and soul crushing that may be, but that my loved one’s comfort was still utmost in my mind.  It would be hard to put their own comfort over my own sadness at the thought of losing them and the potential guilt of saying don’t do anything.

Another patient we saw had metastatic cancer, was severely cachetic and had recurrent malignant ascites that had to be drained every few days.  The patient refused to face her mortality and asked for aggressive treatment throughout her demise because she had a young child at home.  It was heart-breaking.  On one hand I felt so upset that she had this horrible disease at a relatively young age and on the other I was upset that she couldn’t see things as they were and accept palliative care that would have given her a much higher quality of life that she could spend with her children.  But then again I don’t have kids.

One of my team’s patients had a stroke while in the hospital, the very day my team had been debating putting them on anticoagulation.  Amazingly the whole family was there when it happened and the toddler-aged great-grandkids were there to comfort the patient as well.  My attending and the attending on the neurology consult team had a long discussion with the family about whether tPA (fibrinolytic therapy aka clot-busting therapy) would be appropriate or not.  Despite the neurologist telling them he wouldn’t choose to give it to his own parent in that state, the family chose to give tPA.  It was an understandable choice as their loved one was the head of the family and obviously well-beloved.  But at what point do we say enough is enough?

It’s impossible for us as physicians to understand every emotion and thought that occurs to our patients, but I’ve learned that it’s our job and our priviledge to offer our patients every comfort and multiple options of treatment including “non-treatment.”  I’ve read multiple articles and papers on palliative care and how it provides comfort, higher quality of life, acceptance, help with little things around the home, dignity and actually prolongs life by a few weeks to months in many cases.  And palliative care is not giving up like most people would think, what I thought coming into medicine.  But now I realize the importance of it.   The first patient I wrote about was able to get a bedside commode, home oxygen therapy and a hospital-like bed all at home through palliative care while still maintaining her current treatment regimen.  The cost of healthcare from patients who choose every possible treatment until the end is exorbitant and often does not result in good quality of life, and physicians know that.  But we have the mantra that if the patient wants fourth line and fifth line treatment, then that is their prerogative.  But maybe as physicians we need to educate better and support patients through EOL instead of fueling our patients denial and inacceptance.

A final example: one patient we saw also had metastatic cancer, and he was ready to accept EOL and enjoy the time he had left, but his family kept pushing him to seek out further treatment.  He didn’t want to let them down and so he was amenable to it.  I’m not sure what the final decision was but it must have been tough for everyone.  Looking objectively from the outside I wanted to tell the family to let him decide and be supportive of the life he has left to live instead of subjecting him to chemo with its terrible side effects and low chance of success in his case.  But then again, I wasn’t part of his family.  I didn’t know him for 10, 20, 30 or 40 years.  I didn’t grow up with him.  I didn’t raise him.  And so I can only imagine that it might feel like “giving up” on him and choosing to “let him die.”  But back before we had all these ridiculously amazing medical advancements, people “let” their loved ones die 1) because they had little choice but 2) to have time to accept it and to comfort their loved one.

So what has changed?  Do we as a society believe that we should prolong life as long as we possibly can?  Do we believe that we can cure anyone with just the right combination of treatment?  Do we think that by saying we don’t want resuscitative measures that we are choosing to die?  That we are facilitating our own suicide by choosing not to take chemo or have CPR done or be on a ventilator?  I’m not sure.  But it’s the fortunate/unfortunate consequence of living in a technologically and medically advanced world that isn’t quite advanced enough to cure everything.

I knew before coming into third year that these issues would come up often, but I did not realize the full implications of these choices until I saw it before my own eyes.  Doctors are only prolonging the inevitable and hopefully making that prolongation high quality.  So when do we say quantity is worse than the quality?  And when do we say we can’t play God anymore?  And when do we say a person is dead or is surely going to die without regaining higher neurological function?  These questions are by no means clear cut, and even if their are a few guidelines to quantify brain death, it can be quite difficult to assess whether a patient meets criteria for death otherwise.  I just read last night that the 2011 doctor survey that looks at quality of life, pay scale, how many hours worked, etc. by each specialty, the overwhelming majority of physicians in America would choose palliative care over aggressive care if they were faced with a terminal illness.  I’ve heard that before, but now I’ve seen evidence.  And I can’t say I feel differently right now.

So what’s the answer?  What am I gaining by writing down these thoughts?  It hasn’t helped me to figure out the answer, that’s for sure.  But I feel that EOL is a crucial topic to discuss, not only for my patients’ lives, but for my family’s lives, for my own life, for the future philosophy of the world.  Maybe I’m going too far there, maybe not.  But it’s something to ponder.  Should we give up on everyone who “might” die?  Absolutely not.  Should we turn EOL into what will save us money even if it comprises our patients just a little?  Absolutely not.  But how can we justify spending insane amounts of money on treatment that we, as healthcare providers, know almost certainly won’t work.  We would never send a shuttle up into space if we thought it had very little chance of success and cost a ton of money and suffering.  We wouldn’t douse all our trees in four and five types of pesticides in one summer to try to kill mosquitos if we didn’t think it would work and would have potentially really bad side effects and be really expensive.  Most of us wouldn’t use every last resource to cure our pet of rabies or cancer with four or five series of treatments if we thought it would make them more miserable than living out their natural course with the disease.  So why do we do this with humans?  I understand the ridiculously strong human bond that exists that doesn’t exist for the previous examples, but why are we willing to suffer through horrible things and allow our loved ones to suffer through horrible things only to prolong the inevitable?  And why do we even treat things at all if we are only prolonging our imminent deaths?  Because miracles happen.  Because medicine allows us to gain health back.  Because that’s the wonder and amazingness of the human spirit and the desire to live on to be with our loved ones. Thus, these questions go unanswered by me, probably by you, definitely by most everyone.

•  Cool thing I learned today: I learned that I get to be at the newborn nursery next week!!!!! I’m SO excited for pediatrics!
• Medical Spanish of the day: I admit I’ve been slacking since studying the past few weeks for my medicine shelf exam, so I will report back later on this one…
• Tip for medical school: As I see all the hopeful interviewees around campus I feel for them.  They look so nervous, so lost, so dressed up.  I wonder what I looked like.  Probably ridiculous.  Good luck to everyone interviewing!  The key is to be confident, have fun, be at ease, make appropriate jokes and don’t take yourself too seriously.  Even if you think you blew your interview, you probably didn’t. =)

Cool piece about palliative care:  http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande